Provider Demographics
NPI:1124268370
Name:DRAKE, JUSTIN (PHARM D)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-1028
Mailing Address - Country:US
Mailing Address - Phone:304-845-0390
Mailing Address - Fax:304-845-0391
Practice Address - Street 1:115 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-1028
Practice Address - Country:US
Practice Address - Phone:304-845-0390
Practice Address - Fax:304-845-0391
Is Sole Proprietor?:No
Enumeration Date:2009-03-01
Last Update Date:2009-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV7019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist